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Meng CF, Rajesh DA, Jannat-Khat DP, Jivanelli B, Bykerk V. The Gap in Knowledge about Tapering Targeted Therapy being used as Monotherapy in Rheumatoid Arthritis: A Systematic Review. Curr Rheumatol Rev 2024; 20:46-56. [PMID: 37641998 DOI: 10.2174/1573397119666230828160108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/24/2023] [Accepted: 08/04/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Up to 30% of patients with RA are being treated with biologic (b)-disease modifying anti-rheumatic drugs (DMARDs) as monotherapy. Monotherapy with Interleukin (IL)-6 inhibitors(i) and Janus-kinase (JAK)-i has been shown to be effective. Whether patients can taper targeted therapy (bDMARDs and JAK-i) used as monotherapy (targeted monotherapy) is unknown. OBJECTIVE To determine the feasibility of tapering of targeted monotherapy in patients with controlled RA. METHODS We conducted a literature search in Medline, Embase and Cochrane Library for prospective studies reporting remission outcomes after tapering targeted monotherapy in RA patients, from 1/2014 - 8 /2021. RESULTS 5 randomized studies which met our inclusion criteria, evaluating tapering of monotherapy with tumor necrosis factor-inhibitors, tocilizumab, abatacept and baricitinib in RA. Studies were heterogeneous. Three trials studied early RA. Three studies gradually tapered therapy, including 1 dose reduction study. Three studies tapered both biological and conventional-synthetic (cs)-DMARDs. No study compared stopping targeted monotherapy to continuing it. Remission rates were low 14-28% across all studies that stopped targeted monotherapy. The highest remission rate of 72% was reported by the dose reduction study. Trials that studied early RA reported remission rates after tapering ranging 27-72%. Trials tapering therapy in established RA reported rates of remission from 14-20%. CONCLUSION There is a crucial gap in published literature to inform on tapering targeted monotherapy in patients with RA. Stopping targeted monotherapy is unlikely to maintain disease control in RA. Dose reduction strategies and early treatment of disease may be associated with more successful tapering, and warrant future study.
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Affiliation(s)
- Charis F Meng
- Division of Rheumatology, Hospital for Special Surgery, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, USA
| | - Diviya A Rajesh
- Division of Rheumatology, Hospital for Special Surgery, New York, USA
| | - Deanna P Jannat-Khat
- Division of Rheumatology, Epidemiology and Biostatistics CORE, Hospital for Special Surgery, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, USA
| | - Bridget Jivanelli
- Kim Barrett Memorial Library, HSS Education Institute, Hospital for Special Surgery, New York, NY, Weill Cornell Medical College, New York, USA
| | - Vivian Bykerk
- Division of Rheumatology, Hospital for Special Surgery, New York, USA
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2
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Ward MM, Madanchi N, Yazdanyar A, Shah NR, Constantinescu F. Prevalence and predictors of sustained remission/low disease activity after discontinuation of induction or maintenance treatment with tumor necrosis factor inhibitors in rheumatoid arthritis: a systematic and scoping review. Arthritis Res Ther 2023; 25:222. [PMID: 37986101 PMCID: PMC10659063 DOI: 10.1186/s13075-023-03199-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND To determine the prevalence of sustained remission/low disease activity (LDA) in patients with rheumatoid arthritis (RA) after discontinuation of tumor necrosis factor inhibitors (TNFi), separately in induction treatment and maintenance treatment studies, and to identify predictors of successful discontinuation. METHODS We performed a systematic literature review of studies published from 2005 to May 2022 that reported outcomes after TNFi discontinuation among patients in remission/LDA. We computed prevalences of successful discontinuation by induction or maintenance treatment, remission criterion, and follow-up time. We performed a scoping review of predictors of successful discontinuation. RESULTS Twenty-two induction-withdrawal studies were identified. In pooled analyses, 58% (95% confidence interval (CI) 45, 70) had DAS28 < 3.2 (9 studies), 52% (95% CI 35, 69) had DAS28 < 2.6 (9 studies), and 40% (95% CI 18, 64) had SDAI ≤ 3.3 (4 studies) at 37-52 weeks after discontinuation. Among patients who continued TNFi, 62 to 85% maintained remission. Twenty-two studies of maintenance treatment discontinuation were also identified. At 37-52 weeks after TNFi discontinuation, 48% (95% CI 38, 59) had DAS28 < 3.2 (10 studies), and 47% (95% CI 33, 62) had DAS28 < 2.6 (6 studies). Heterogeneity among studies was high. Data on predictors in induction-withdrawal studies were limited. In both treatment scenarios, longer duration of RA was most consistently associated with less successful discontinuation. CONCLUSIONS Approximately one-half of patients with RA remain in remission/LDA for up to 1 year after TNFi discontinuation, with slightly higher proportions in induction-withdrawal settings than with maintenance treatment discontinuation.
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Affiliation(s)
- Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Building 10CRC, Room 4-1339, 10 Center Drive, Bethesda, MD, 20892-1468, USA.
| | - Nima Madanchi
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
- Current address: Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ali Yazdanyar
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA, USA
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
- Current address: Division of Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nehal R Shah
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
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3
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Chen SF, Yeh FC, Chen CY, Chang HY. Tailored therapeutic decision of rheumatoid arthritis using proteomic strategies: how to start and when to stop? Clin Proteomics 2023; 20:22. [PMID: 37301840 DOI: 10.1186/s12014-023-09411-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Unpredictable treatment responses have been an obstacle for the successful management of rheumatoid arthritis. Although numerous serum proteins have been proposed, there is a lack of integrative survey to compare their relevance in predicting treatment outcomes in rheumatoid arthritis. Also, little is known about their applications in various treatment stages, such as dose modification, drug switching or withdrawal. Here we present an in-depth exploration of the potential usefulness of serum proteins in clinical decision-making and unveil the spectrum of immunopathology underlying responders to different drugs. Patients with robust autoimmunity and inflammation are more responsive to biological treatments and prone to relapse during treatment de-escalation. Moreover, the concentration changes of serum proteins at the beginning of the treatments possibly assist early recognition of treatment responders. With a better understanding of the relationship between the serum proteome and treatment responses, personalized medicine in rheumatoid arthritis will be more achievable in the near future.
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Affiliation(s)
- Shuo-Fu Chen
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fu-Chiang Yeh
- Division of Rheumatology, Immunology and Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ching-Yun Chen
- Department of Biomedical Sciences and Engineering, Institute of Biomedical Engineering and Nanomedicine, National Central University, Taoyuan, Taiwan
- Institute of Biomedical Engineering and Nanomedicine, National Health Research Institutes, Miaoli, Taiwan
| | - Hui-Yin Chang
- Department of Biomedical Sciences and Engineering, Institute of Systems Biology and Bioinformatics, National Central University, No. 300, Zhongda Rd., Zhongli District, Taoyuan, 320317, Taiwan.
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4
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van der Togt CJT, Van den Bemt B, Aletaha D, Alten R, Chatzidionysiou K, Galloway J, Isaac J, Mulleman D, Verschueren P, Vulto AG, Welsing PMJ, Verhoef L, den Broeder AA. Points to consider for cost-effective use of biological and targeted synthetic DMARDs in inflammatory rheumatic diseases: results from an umbrella review and international Delphi study. RMD Open 2023; 9:rmdopen-2022-002898. [PMID: 36863753 PMCID: PMC9990692 DOI: 10.1136/rmdopen-2022-002898] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/08/2023] [Indexed: 03/04/2023] Open
Abstract
OBJECTIVES To develop evidence-based points to consider for cost-effective use of biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in the treatment of inflammatory rheumatic diseases, specifically rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis. METHODS Following EULAR procedures, an international task force was formed, consisting of 13 experts in rheumatology, epidemiology and pharmacology from seven European countries. Twelve strategies for cost-effective use of b/tsDMARDs were identified through individual and group discussion. For each strategy, PubMed and Embase were systematically searched for relevant English-language systematic reviews and, for six strategies, additionally for randomised controlled trials (RCTs). Thirty systematic reviews and 21 RCTs were included. Based on the evidence, a set of overarching principles and points to consider was formulated by the task force using a Delphi procedure. Level of evidence (1a-5) and grade (A-D) were determined for each point to consider. Individual voting on the level of agreement (LoA; between 0 (completely disagree) and 10 (completely agree)) was performed anonymously. RESULTS The task force agreed on five overarching principles. For 10 of 12 strategies, the evidence was sufficient to formulate one or more points to consider, leading to 20 in total, regarding response prediction, drug formulary use, biosimilars, loading doses, low-dose initial therapy, concomitant conventional synthetic DMARD use, route of administration, medication adherence, disease activity-guided dose optimisation and non-medical drug switching. Ten points to consider (50%) were supported by level 1 or 2 evidence. The mean LoA (SD) varied between 7.9 (1.2) and 9.8 (0.4). CONCLUSION These points to consider can be used in rheumatology practices and complement inflammatory rheumatic disease treatment guidelines to incorporate cost-effectiveness in b/tsDMARD treatment.
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Affiliation(s)
- Céleste J T van der Togt
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands .,Department of Rheumatology, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Bart Van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Pharmacy, Radboudumc, Nijmegen, The Netherlands
| | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Wien, Austria
| | - Rieke Alten
- Internal Medicine, Rheumatology, Schlosspark-Klinik GmbH, Berlin, Germany
| | | | - James Galloway
- Department of Rheumatology, King's College London, London, UK
| | - John Isaac
- Department of Rheumatology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Denis Mulleman
- Department of Rheumatology, University of Tours, Tours, France.,Service de Rhumatologie, CHRU Tours, Tours, France
| | - P Verschueren
- Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Arnold G Vulto
- Department of Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - Paco M J Welsing
- Rheumatology and Clinical Immunology, UMC Utrecht, Utrecht, The Netherlands
| | - Lise Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
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5
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Kerschbaumer A, Sepriano A, Bergstra SA, Smolen JS, van der Heijde D, Caporali R, Edwards CJ, Verschueren P, de Souza S, Pope JE, Takeuchi T, Hyrich KL, Winthrop KL, Aletaha D, Stamm TA, Schoones JW, Landewé RBM. Efficacy of synthetic and biological DMARDs: a systematic literature review informing the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis 2023; 82:95-106. [PMID: 36368906 DOI: 10.1136/ard-2022-223365] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/10/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To update the evidence on efficacy of DMARDs (disease-modifying antirheumatic drugs) and inform the taskforce of the 2022 update of the European Alliance of Associations for Rheumatology (EULAR) recommendations for management of rheumatoid arthritis (RA). METHODS This systematic literature review (SLR) investigated the efficacy of conventional synthetic (cs), biological (b), biosimilar and targeted synthetic (ts)DMARDs in patients with RA. Medline, EMBASE, Cochrane CENTRAL and Web of Science were used to identify all relevant articles published since the previous update in 2019 to 14 January 2022. RESULTS Of 8969 search results, 169 articles were selected for detailed review and 47 were finally included. Trials investigated the efficacy of csDMARDs, bDMARDs and tsDMARDs, DMARD switching, tapering and trials investigating different treatment strategies. The compounds investigated were csDMARDs (methotrexate (MTX), leflunomide, sulfasalazine, hydroxychloroquine), bDMARDs (abatacept, adalimumab, certolizumab-pegol, denosumab, etanercept, infliximab, levilimab, olokizumab, opineracept, rituximab, sarilumab, tocilizumab) and tsDMARDs (baricitinib, filgotinib, tofacitinib, upadacitinib). The efficacy of csDMARDs+ short-term glucocorticoids in early RA was confirmed and similar to bDMARD+MTX combination therapy. Interleukin-6 pathway inhibition was effective in trials on olokizumab and levilimab. Janus kinase inhibitor (JAKi) was efficacious in different patient populations. After insufficient response to JAKi, patients could respond to TNFi treatment. Tapering of DMARDs was feasible for a proportion of patients, who were able to taper therapy while remaining in low disease activity or remission. CONCLUSION The results of this SLR, together with one SLR on safety of DMARD and one on glucocorticoids, informed the taskforce of the 2022 update of the EULAR recommendations for pharmacological management of RA.
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Affiliation(s)
- Andreas Kerschbaumer
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Alexandre Sepriano
- CHRC Campus Nova Medical School, Universidade Nova de Lisboa, Lisboa, Portugal.,Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Josef S Smolen
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | | | | | - Christopher John Edwards
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Patrick Verschueren
- Department of Rheumatology, University Hospitals Leuven and Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Savia de Souza
- Patient Research Partner Network, European Alliance of Associations for Rheumatology, Zurich, Switzerland
| | - Janet E Pope
- Schulich School of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester and NIHR Manchester Biomedical Research Centre, Manchester University NHS Trust, Manchester, UK
| | - Kevin L Winthrop
- School of Public Health, Oregon Health & Science University, Portland, Oregon, USA
| | - Daniel Aletaha
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Tanja A Stamm
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert B M Landewé
- Amsterdam Rheumatology Center, AMC, Amsterdam, The Netherlands.,Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
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6
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Mori S, Okada A, Koga T, Ueki Y. Long-term outcomes after discontinuing biological drugs and tofacitinib in patients with rheumatoid arthritis: A prospective cohort study. PLoS One 2022; 17:e0270391. [PMID: 35737642 PMCID: PMC9223309 DOI: 10.1371/journal.pone.0270391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/09/2022] [Indexed: 11/30/2022] Open
Abstract
Objective This study examined long-term outcomes of biological disease-modifying antirheumatic drugs (bDMARDs) and tofacitinib discontinuation in patients with rheumatoid arthritis (RA). Methods Ninety-seven RA patients who desired drug discontinuation after sustained remission or low disease activity for at least 48 weeks due to stable treatment with biological drugs or tofacitinib were enrolled into this study. All patients were prospectively followed until disease flare or the end of the study. Discontinued drugs (previous drugs) were reintroduced to treat flares. Results Following bDMARD/tofacitinib discontinuation (mean follow-up, 2.1 years; standard deviation, 2.0), disease flare occurred at a crude incidence rate of 0.36 per person-year. The median time to flare was 1.6 years (95% confidence interval [CI] 0.9–2.6), and the cumulative flare probability was estimated to be 45% at 1 year, 64% at 3 years, and 80% at 5 years. No or little radiological progression was shown in 87.1% of patients who maintained remission for 3 years. A Fine‒Gray competing risk regression analysis showed that predictive factors for a flare were longer RA duration at the start of bDMARD/tofacitinib treatment, previous failure of treatment with bDMARDs, and a shorter period of remission or low disease activity before drug discontinuation. Type of discontinued drug was not identified as a predictive factor after adjusting for other predictor variables. Restarting previous treatment regimens led to rapidly regaining disease control in 89% of flare patients within 1 month. Conclusion Discontinuation of bDMARD/tofacitinib may be a feasible strategy in RA patients, especially patients with early treated and longer-controlled RA. Flares are manageable in most RA patients and radiological progression is rare for at least 3 years in patients with sustained remission after bDMARD/tofacitinib discontinuation.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, National Hospital Organization Kumamoto Saishun Medical Center, Kohshi, Kumamoto, Japan
- * E-mail:
| | - Akitomo Okada
- Department of Rheumatology, Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan
| | - Tomohiro Koga
- Division of Advanced Preventive Medical Sciences, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Center for Bioinformatics and Molecular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yukitaka Ueki
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Sasebo, Nagasaki, Japan
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7
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Tascilar K, Hagen M, Kleyer A, Simon D, Reiser M, Hueber AJ, Manger B, Englbrecht M, Finzel S, Tony HP, Schuch F, Kleinert S, Wendler J, Ronneberger M, Figueiredo CP, Cobra JF, Feuchtenberger M, Fleck M, Manger K, Ochs W, Schmitt-Haendle M, Lorenz HM, Nuesslein H, Alten R, Kruger K, Henes J, Schett G, Rech J. Treatment tapering and stopping in patients with rheumatoid arthritis in stable remission (RETRO): a multicentre, randomised, controlled, open-label, phase 3 trial. THE LANCET. RHEUMATOLOGY 2021; 3:e767-e777. [PMID: 38297524 DOI: 10.1016/s2665-9913(21)00220-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 02/02/2024]
Abstract
BACKGROUND Owing to increasing remission rates, the management of patients with rheumatoid arthritis in sustained remission is of growing interest. The Rheumatoid Arthritis in Ongoing Remission (RETRO) study investigated tapering and withdrawal of disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis in stable remission to test whether remission could be retained without the need to take DMARD therapy despite an absence of symptoms. METHODS RETRO was an investigator-initiated, multicentre, prospective, randomised, controlled, open-label, parallel-group phase 3 trial in patients aged at least 18 years with rheumatoid arthritis for at least 12 months before randomisation who were in sustained Disease Activity Score using 28 joints with erythrocyte sedimentation rate (ESR) remission (score <2·6 units). Eligible patients were recruited consecutively from 14 German hospitals or rheumatology practices and randomly assigned (1:1:1) without stratification and regardless of baseline treatment, using a sequence that was computer-generated by the study statistician, to continue 100% dose DMARD (continue group), taper to 50% dose DMARD (taper group), or 50% dose DMARD for 6 months before stopping DMARDs (stop group). Neither patients nor investigators were masked to the treatment assignment. Patients were assessed every 3 months and screened for disease activity and relapse. The primary endpoint was the proportion of patients in sustained DAS28-ESR remission without relapse at 12 months, analysed using a log-rank test of trend and Cox regression. Analysis by a trained statistician of the primary outcome and safety was done in a modified intention-to-treat population that included participants with non-missing baseline data. This study is completed and closed to new participants and is registered with ClinicalTrials.gov (NCT02779114). FINDINGS Between May 26, 2010, and May 29, 2018, 303 patients were enrolled and allocated to continue (n=100), taper (n=102), or stop DMARDs (n=101). 282 (93%) of 303 patients were analysed (93 [93%] of 100 for continue, 93 [91%] of 102 for taper, and 96 [95%] of 101 for stop). Remission was maintained at 12 months by 81·2% (95% CI 73·3-90·0) in the continue group, 58·6% (49·2-70·0) in the taper group, and 43·3% (34·6-55·5) in the stop group (p=0·0005 with log-rank test for trend). Hazard ratios for relapse were 3·02 (1·69-5·40; p=0.0003) for the taper group and 4·34 (2·48-7·60; p<0.0001)) for the stop group, in comparison with the continue group. The majority of patients who relapsed regained remission after reintroduction of 100% dose DMARDs. Serious adverse events occurred in ten of 93 (11%) patients in the continue group, seven of 93 (8%) patients in taper group, and 13 of 96 (14%) patients in the stop group. None were considered to be related to the intervention. The most frequent type of serious adverse event was injuries or procedural complications (n=9). INTERPRETATION Reducing antirheumatic drugs in patients with rheumatoid arthritis in stable remission is feasible, with maintenance of remission occurring in about half of the patients. Because relapse rates were significantly higher in patients who tapered or stopped antirheumatic drugs than in patients who continued with a 100% dose, such approaches will require tight monitoring of disease activity. However, remission was regained after reintroduction of antirheumatic treatments in most of those who relapsed in this study. These results might help to prevent overtreatment in a substantial number of patients with rheumatoid arthritis. FUNDING None.
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Affiliation(s)
- Koray Tascilar
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Melanie Hagen
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Arnd Kleyer
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - David Simon
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Michaela Reiser
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Axel J Hueber
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany; Rheumatology Section, Sozialstiftung Bamberg, Bamberg, Germany
| | - Bernhard Manger
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Matthias Englbrecht
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Stephanie Finzel
- Department of Rheumatology and Clinical Immunology, University of Freiburg, Freiburg, Germany
| | - Hans-Peter Tony
- Department of Internal Medicine 2, University of Wuerzburg, Wuerzburg, Germany
| | | | - Stefan Kleinert
- Department of Internal Medicine 2, University of Wuerzburg, Wuerzburg, Germany; Rheumatology Practice, Erlangen, Germany
| | | | | | - Camille P Figueiredo
- Division of Rheumatology, Faculty of Medicine, Sao Paulo University, Sao Paulo, Brazil
| | | | - Martin Feuchtenberger
- Rheumatology Practice and Department of Internal Medicine 2, Clinic Burghausen, Burghausen, Germany
| | - Martin Fleck
- Department of Internal Medicine I, University of Regensburg, Regensburg, Germany; Asklepios Medical Center Bad Abbach, Bad Abbach, Germany
| | | | | | | | - Hanns-Martin Lorenz
- Department of Internal Medicine V, Division of Rheumatology, University of Heidelberg, Heidelberg, Germany
| | | | | | | | - Joerg Henes
- Department of Internal Medicine 2, University of Tubingen, Tubingen, Germany
| | - Georg Schett
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany.
| | - Juergen Rech
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
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8
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Infliximab Treatment Does Not Lead to Full TNF-α Inhibition: A Target-Mediated Drug Disposition Model. Clin Pharmacokinet 2021; 61:143-154. [PMID: 34351609 DOI: 10.1007/s40262-021-01057-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Infliximab, an anti-tumour necrosis factor (TNF)-α monoclonal antibody, has been approved in chronic inflammatory disease, including rheumatoid arthritis, Crohn's disease and ankylosing spondylitis. This study aimed to investigate and characterise target-mediated drug disposition of infliximab and antigen mass turnover during infliximab treatment. METHODS In this retrospective cohort of 186 patients treated with infliximab for rheumatoid arthritis, Crohn's disease or ankylosing spondylitis, trough infliximab concentrations were determined from samples collected between weeks 0 and 22 after treatment initiation. Target-mediated pharmacokinetics of infliximab was described using target-mediated drug disposition modelling. Target-mediated elimination parameters were determined for rheumatoid arthritis and Crohn's disease, assuming ankylosing spondylitis with no target-mediated elimination. RESULTS The quasi-equilibrium approximation of a target-mediated drug disposition model allowed a satisfactory description of infliximab concentration-time data. Estimated baseline TNF-α amounts were similar in Crohn's disease and rheumatoid arthritis (R0 = 0.39 vs 0.46 nM, respectively), but infliximab-TNF complex elimination was slower in Crohn's disease than in rheumatoid arthritis (kint = 0.024 vs 0.061 day-1, respectively). Terminal elimination half-lives were 13.5, 21.5 and 16.5 days for rheumatoid arthritis, Crohn's disease and ankylosing spondylitis, respectively. Estimated amounts of free target were close to baseline values before the next infusion suggesting that TNF-α inhibition may not be sustained over the entire dose interval. CONCLUSIONS The present study is the first to quantify the influence of target antigen dynamics on infliximab pharmacokinetics. Target-mediated elimination of infliximab may be complex, involving a multi-scale turnover of TNF-α, especially in patients with Crohn's disease. Additional clinical studies are warranted to further evaluate and fine-tune dosing approaches to ensure sustained TNF-α inhibition.
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9
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Prediction of disease flare by biomarkers after discontinuing biologics in patients with rheumatoid arthritis achieving stringent remission. Sci Rep 2021; 11:6865. [PMID: 33767314 PMCID: PMC7994312 DOI: 10.1038/s41598-021-86335-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/08/2021] [Indexed: 11/08/2022] Open
Abstract
To elucidate the disease-flare process in rheumatoid arthritis (RA) after discontinuing biological disease-modifying antirheumatic drugs (bDMARDs), we first focused on RA-flare prediction after achieving stringent remission criteria. Patients with RA who maintained a simplified disease activity index ≤ 3.3 for ≥ 3 months during November 2014-January 2018 in our medical centre in Tokyo, Japan, were eligible. The primary endpoint was flare (disease activity score 28-erythrocyte sedimentation rate ≥ 3.2 with increase from baseline > 0.6) within 2 years after bDMARD discontinuation. Comprehensive clinical assessments, ultrasonographic evaluation of 40 joints, and blood sampling for 12 biomarkers were performed every 2-3 months for 2 years unless patients experienced flare. Flare-positive and flare-negative patients were compared using univariate and Kaplan-Meier analyses. Thirty-six patients (80.6% female, median disease duration, 5.2 years; median treatment period with discontinued bDMARD, 2 years; median remission duration, 18 months) were enrolled. Twenty patients (55.6%) experienced RA flare 43-651 (median, 115) days after the first skipped date of bDMARDs. Two patients who withdrew without disease flare were excluded from the comparison. Clinical and ultrasonographic evaluations did not show significant between-group differences; Kaplan-Meier analysis showed that higher baseline soluble tumour necrosis factor receptor 1 (sTNFR1) concentration impacted subsequent disease flare (p = 0.0041); higher baseline interleukin (IL)-2 concentration was exclusively beneficial to patients with lower sTNFR1 (p = 0.0058), resulting in remission maintenance in 83.3% of patients with lower sTNFR1 and higher IL-2. We demonstrated the usefulness of combined biomarker evaluation for predicting sustained remission after bDMARD discontinuation in RA.
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Ochiai M, Tanaka E, Sato E, Inoue E, Abe M, Saka K, Sugano E, Sugitani N, Higuchi Y, Yamaguchi R, Sugimoto N, Ikari K, Nakajima A, Yamanaka H, Harigai M. Successful discontinuation of biological disease-modifying antirheumatic drugs in patients with rheumatoid arthritis in real-world settings. Mod Rheumatol 2021; 31:790-795. [PMID: 33538611 DOI: 10.1080/14397595.2021.1883252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To analyze the proportion of successful biological disease-modifying antirheumatic drugs (bDMARDs) discontinuation and related factors in patients with rheumatoid arthritis (RA) in clinical settings. METHODS Among 1775 RA patients who started bDMARDs between 2003 and 2012, 43 patients with DAS28-ESR <3.2 at the time of bDMARD discontinuation were extracted. Patients were divided into two groups (bio-free success: BS and bio-free failure: BF groups) based on bDMARD usage and disease activity 1 year after discontinuation. We evaluated the proportion of bio-free success and assessed factors related to bio-free success. RESULTS Twenty-five patients (58.1%: BS group) maintained discontinuation of bDMARDs and DAS28-ESR <3.2 at 1 year after discontinuation. The median DAS28-ESR at bDMARD initiation was lower in the BS group than in the BF group (3.95 vs 5.04; p = .04). The BS group experienced a larger decrease in average glucocorticoid (GC) dose during bDMARD use than the BF group (-3.0 mg/day vs 0 mg/day; p = .01). CONCLUSION bDMARDs were discontinued without flare up of RA in 58.1% of patients with RA in clinical settings. A lower DAS28-ESR at initiation and reduction of GC dose before discontinuation of bDMARD were important factors associated with bio-free success.
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Affiliation(s)
- Moeko Ochiai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eiichi Tanaka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eri Sato
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Keyaki Total Clinic, Chiba, Japan
| | - Eisuke Inoue
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Research Administration Center, Showa University, Tokyo, Japan
| | - Mai Abe
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Kumiko Saka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eri Sugano
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Naohiro Sugitani
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yoko Higuchi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Rei Yamaguchi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Naoki Sugimoto
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Katsunori Ikari
- Department of Orthopedics, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Ayako Nakajima
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Center for Rheumatic Diseases, Mie University Hospital, Mie, Japan
| | - Hisashi Yamanaka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Rheumatology, Sanno Medical Center, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Takai C, Ito S, Kobayashi D, Nemoto T, Lee H, Abe A, Otani H, Nakazono K, Murasawa A, Ishikawa H. Two-year Outcomes of Infliximab Discontinuation in Patients with Rheumatoid Arthritis: A Retrospective Analysis from a Single Center. Intern Med 2020; 59:1963-1970. [PMID: 32801270 PMCID: PMC7492115 DOI: 10.2169/internalmedicine.3934-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective To investigate the clinical outcomes of rheumatoid arthritis (RA) patients who discontinued infliximab (IFX) treatment at our hospital. Methods Among 249 patients receiving IFX from 2007 to 2015, we retrospectively investigated the clinical courses of 18 who discontinued IFX after achieving the 28-joint disease activity score based on the erythrocyte sedimentation (DAS28-ESR) clinical remission (CR) and whose clinical courses were available continuously for 96 weeks after discontinuation. Results At IFX introduction, the median age was 56.9 (range 36.1-72.4) years, and the disease duration was 5.2 (0.4-25.6) years. The median duration of maintaining either CR or a low disease activity (LDA) with IFX was 37.2 (4.0-91.4) months, and the total duration of IFX therapy was 45.8 (17.1-96.9) months. After discontinuation, 8 patients (44.4%) maintained CR/LDA for 96 weeks (no-flare group), and 10 (55.6%) experienced flares (DAS28-ESR≥3.2) within 96 weeks (flare group). In the no-flare group, six patients receiving intensified conventional synthetic disease-modifying antirheumatic drug (csDMARD) therapy to prevent flare ups simultaneously either with or immediately after discontinuing IFX. In the flare group, four patients received intensified csDMARD therapy. Six patients restarted biological DMARDs (bDMARDs), and all achieved CR again. Ultimately, 12 patients (66.7%) maintained a Bio-free disease control for 96 weeks. A comparison of the clinical backgrounds between the flare and no-flare groups showed no marked difference in their disease duration, IFX dosage, duration of maintaining CR with IFX, or concomitant csDMARDs use. Conclusion Irrespective of the RA disease duration, more than half of all patients maintained a Bio-free condition for 96 weeks. Continuing LDA with IFX for a sufficiently long period of time before discontinuation and preventive intensification of csDMARD therapy may help maintain a Bio-free condition.
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Affiliation(s)
- Chinatsu Takai
- Department of Rheumatology, Niigata Rheumatic Center, Japan
| | - Satoshi Ito
- Department of Rheumatology, Niigata Rheumatic Center, Japan
| | - Daisuke Kobayashi
- Department of Rheumatology, Niigata Rheumatic Center, Japan
- Division of Clinical Nephrology and Rheumatology Niigata University Graduate School of Medical and Dental Sciences, Japan
| | - Tetsuya Nemoto
- Department of Rheumatology, Niigata Rheumatic Center, Japan
- Department of Orthopaedic Surgery, Showa University School of Medicine, Japan
| | - Hyunho Lee
- Department of Rheumatology, Niigata Rheumatic Center, Japan
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Japan
| | - Asami Abe
- Department of Rheumatology, Niigata Rheumatic Center, Japan
| | - Hiroshi Otani
- Department of Rheumatology, Niigata Rheumatic Center, Japan
| | | | - Akira Murasawa
- Department of Rheumatology, Niigata Rheumatic Center, Japan
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Tanaka Y, Oba K, Takeuchi T. Response to: 'Comment on 'Sustained discontinuation of infliximab with a raising-dose strategy after obtaining remission in patients with rheumatoid arthritis: the RRRR study, a randomised controlled trial' by Tanaka et al' by Berkhout et al. Ann Rheum Dis 2019; 80:e173. [PMID: 31818809 DOI: 10.1136/annrheumdis-2019-216593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/02/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Koji Oba
- Interfaculty Initiative in Information Studies, The University of Tokyo, Tokyo, Japan
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Berkhout LC, l'Ami MJ, Wolbink GJ, Rispens T. Comment on 'Sustained discontinuation of infliximab with a raising-dose strategy after obtaining remission in patients with rheumatoid arthritis: the RRRR study, a randomised controlled trial' by Tanaka et al. Ann Rheum Dis 2019; 80:e172. [PMID: 31744825 DOI: 10.1136/annrheumdis-2019-216557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 11/01/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Lea C Berkhout
- Immunopathology, Sanquin Research, Amsterdam, The Netherlands
| | - Merel J l'Ami
- Reade, Amsterdam Rheumatology and immunology Center, Amsterdam, The Netherlands
| | - Gerrit Jan Wolbink
- Immunopathology, Sanquin Research, Amsterdam, The Netherlands.,Reade, Amsterdam Rheumatology and immunology Center, Amsterdam, The Netherlands
| | - Theo Rispens
- Immunopathology, Sanquin Research, Amsterdam, The Netherlands
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